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                                                <a  href="index7f32.html?route=product/category&amp;path=57_30">Lorem ipsum dolor sit amet </a>
                            </li>
                                                                                    <li class="">
                                                <a  href="indexf54f.html?route=product/category&amp;path=57_29">Conse ctetur adipisicing</a>
                            </li>
                                                                                    <li class="">
                                                <a  href="index616d.html?route=product/category&amp;path=57_31">Elit sed do eiusmod tempor</a>
                            </li>
                                                                                    <li class="">
                                                <a  href="index2b50.html?route=product/category&amp;path=57_28">Incididunt ut labore</a>
                            </li>
                                        </ul>
                          </li>
                        <li class="cat-header ">
                            <a href="index98dc.html?route=product/category&amp;path=20">Cosmetics</a>
                            </li>
                        <li class="cat-header parent">
                            <a href="indexb152.html?route=product/category&amp;path=17">Diet &amp; Nutrition</a>
                    
                                    <ul>
                                                                                                <li class="">
                                                <a  href="index8bfa.html?route=product/category&amp;path=17_35">Ut labore et </a>
                            </li>
                                                                                    <li class=" parent">
                                                <a  href="indexabd7.html?route=product/category&amp;path=17_32">Litdera</a>
                                <ul>
                                                    <li>
                                        <a href="index0a29.html?route=product/category&amp;path=17_32_36">Dolore magna</a>
                                      </li>
                                  </ul>
                              </li>
                                        </ul>
                          </li>
                        <li class="cat-header ">
                            <a href="indexc957.html?route=product/category&amp;path=24">Gifts &amp; Specialty</a>
                            </li>
                        <li class="cat-header ">
                            <a href="index1647.html?route=product/category&amp;path=25">Household Items</a>
                            </li>
                        <li class="cat-header ">
                            <a href="indexcac5.html?route=product/category&amp;path=75">Medicine Cabinet</a>
                            </li>
                        <li class="cat-header ">
                            <a href="index08bf.html?route=product/category&amp;path=76">Natural Products</a>
                            </li>
                        <li class="cat-header ">
                            <a href="indexdb3b.html?route=product/category&amp;path=77">Exclusives</a>
                            </li>
                        <li class="cat-header ">
                            <a href="indexaf75.html?route=product/category&amp;path=78">Shopping Aisles</a>
                            </li>
                        <li class="cat-header ">
                            <a href="indexc94f.html?route=product/category&amp;path=79">Personal Care</a>
                            </li>
                        <li class="cat-header ">
                            <a href="index460c.html?route=product/category&amp;path=80">Sexual Health</a>
                            </li>
                        <li class="cat-header ">
                            <a href="index33b9.html?route=product/category&amp;path=81">Shop By Brand</a>
                            </li>
              </ul>
    </div>
  </div>
</div>
    <div class="box account">
  <div class="box-heading">Account</div>
  <div class="box-content">
    <ul class="acount">
            <li><a href="indexe223.html?route=account/login">Login</a> / <a href="index5502.html?route=account/register">Register</a></li>
      <li><a href="indexacda.html?route=account/forgotten">Forgotten Password</a></li>
            <li><a href="indexe223.html?route=account/account">My Account</a></li>
            <li><a href="indexe223.html?route=account/address">Address Books</a></li>      <li><a href="indexe223.html?route=account/wishlist">Wish List</a></li>
      <li><a href="indexe223.html?route=account/order">Order History</a></li>
      <li><a href="indexe223.html?route=account/download">Downloads</a></li>
      <li><a href="indexe223.html?route=account/return">Returns</a></li>
      <li><a href="indexe223.html?route=account/transaction">Transactions</a></li>
      <li><a href="indexe223.html?route=account/newsletter">Newsletter</a></li>
      <li><a href="indexe223.html?route=account/recurring">Recurring payments</a></li>          </ul>
  </div>
</div>
  </aside>
		<div class="col-sm-9  " id="content">  <div class="breadcrumb">
		<a href="index9328.html?route=common/home">Home</a>
		 &raquo; <a href="indexe223.html?route=account/account">Account</a>
		 &raquo; <a href="indexda9d.html?route=account/return/insert">Product Returns</a>
	  </div>
  <h1 class="style-1">Product Returns</h1>
  <div class="box-container">
	<p>Please complete the form below to request an RMA number.</p>	<form class="form-horizontal" action="http://livedemo00.template-help.com/opencart_48042/index.php?route=account/return/insert" method="post" enctype="multipart/form-data" id="return">
	
	<div class="content content-border">
		<h2>Order Information</h2>
		<div class="form-group">
			<label class="control-label col-sm-5" for="firstname"><span class="required">*</span> First Name:</label>
			<div class="col-sm-7">
				<input type="text" name="firstname" value=""  />
							</div>
		</div>
		<div class="form-group">
			<label class="control-label col-sm-5" for="lastname"><span class="required">*</span> Last Name:</label>
			<div class="col-sm-7">
				<input type="text" name="lastname" value=""  />
							</div>
		</div>
		<div class="form-group">
			<label class="control-label col-sm-5" for="email"><span class="required">*</span> E-Mail:</label>
			<div class="col-sm-7">
				<input type="text" name="email" value=""  />
							</div>
		</div>
		<div class="form-group">
			<label class="control-label col-sm-5" for="telephone"><span class="required">*</span> Telephone:</label>
			<div class="col-sm-7">
				<input type="text" name="telephone" value=""  />
							</div>
		</div>
		<div class="form-group">
			<label class="control-label col-sm-5" for="order_id"><span class="required">*</span> Order ID:</label>
			<div class="col-sm-7">
				<input type="text" name="order_id" value=""  />
							</div>
		</div>
		<div class="form-group">
			<label class="control-label col-sm-5" for="date_ordered">Order Date:</label>
			<div class="col-sm-7">
				<input type="text" name="date_ordered" value="" class="col-sm-4 date" />
			</div>
		</div>
	</div>
	
	<div id="return-product">
	  <div class="content  content-border">
		<h2>Product Information &amp; Reason for Return</h2>
		<div class="return-product">
		  <div class="return-name form-group">
			<label class="control-label col-sm-5" for="product"><span class="required">*</span> <b>Product Name:</b></label>
			<div class="col-sm-7">
				<input type="text" name="product" value=""  />
							</div>
		  </div>
		  <div class="return-model form-group">
			<label class="control-label col-sm-5" for="model"><span class="required">*</span> <b>Product Code:</b></label>
			<div class="col-sm-7">
				<input type="text" name="model" value=""  />
							</div>
		  </div>
		  <div class="return-quantity form-group">
			<label class="control-label col-sm-5" for="model"><b>Quantity:</b></label>
			<div class="col-sm-7">
				<input type="text" name="quantity" value="1"  />
			</div>
		  </div>
		</div>
		<div class="return-detail ">
		  <div class="return-reason form-group">
			<label class="control-label col-sm-5"></label>
			<div class="col-sm-7">
				<label><span class="required">*</span> <b>Reason for Return:</b></label>
					
								<label class="radio" for="return-reason-id1"><input type="radio" name="return_reason_id" value="1" id="return-reason-id1" />Dead On Arrival</label>
									
								<label class="radio" for="return-reason-id4"><input type="radio" name="return_reason_id" value="4" id="return-reason-id4" />Faulty, please supply details</label>
									
								<label class="radio" for="return-reason-id3"><input type="radio" name="return_reason_id" value="3" id="return-reason-id3" />Order Error</label>
									
								<label class="radio" for="return-reason-id5"><input type="radio" name="return_reason_id" value="5" id="return-reason-id5" />Other, please supply details</label>
									
								<label class="radio" for="return-reason-id2"><input type="radio" name="return_reason_id" value="2" id="return-reason-id2" />Received Wrong Item</label>
															</div>
		  </div>
		  <div class="return-opened form-group">
			<label class="control-label col-sm-5"></label>
			<div class="col-sm-7">
				<label><b>Product is opened:</b></label>
				<label class="radio" for="opened">
										<input type="radio" name="opened" value="1" id="opened" />
										Yes				</label>
				<label class="radio" for="unopened">
										<input type="radio" name="opened" value="0" id="unopened" checked="checked" />
										No				</label>
			</div>
		  </div>
		  <div class="return-captcha form-group">
			<label class="control-label col-sm-5">Enter the code in the box below:</label>
			<div class="col-sm-7">
				<input class="col-sm-2" type="text" name="captcha" value="" />
					&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
				<img src="index6765.jpg?route=account/return/captcha" alt="" />
							</div>
		  </div>
		  
		</div>
			<div class="form-group">
				<label class="control-label col-sm-5">Faulty or other details:</label>
				<div class="col-sm-7">
					<textarea  name="comment" cols="150" rows="6"></textarea>
				</div>
			</div>
						<div class="buttons">
			<div class="left"><a href="indexe223.html?route=account/account" class="button-return-left"><i class="fa fa-reply"></i>Back</a></div>
			<div class="right button-return-right-i">
				<input type="submit" value="Continue" class="button-return-right" />
				<i class="fa fa-arrow-circle-right"></i>
			</div>
			</div>
				  </div>
	</div>
	
  </form>
  </div>
  </div>

	
<script type="text/javascript"><!--
$(document).ready(function() {
	$('.date').datepicker({dateFormat: 'yy-mm-dd'});
});
//--></script> 
<script type="text/javascript"><!--
$(document).ready(function() {
	$('.colorbox').fancybox({
		
	});
});
//--></script>
<div class="clear"></div>
</div>
</div>
</div>
<div class="clear"></div>
</section>
<footer>
<div class="footer-top">
<div class="container">
	
		<div class="row">
						<div class="col-sm-3">
				<h3>Information</h3>
				<ul>
								<li><a href="index8816.html?route=information/information&amp;information_id=4">About</a></li>
								<li><a href="index1766.html?route=information/information&amp;information_id=6">Delivery</a></li>
								<li><a href="index1679.html?route=information/information&amp;information_id=3">Privacy Policy</a></li>
								<li><a href="index99e4.html?route=information/information&amp;information_id=5">Terms &amp; Conditions</a></li>
								</ul>
			</div>
						<div class="col-sm-3">
				<h3>Customer Service</h3>
				<ul>
				<li><a href="index2724.html?route=information/contact">Contact Us</a></li>
				<li><a href="indexda9d.html?route=account/return/insert">Returns</a></li>
				<li><a href="index7cb2.html?route=information/sitemap">Site Map</a></li>
				</ul>
			</div>
			<div class="col-sm-3">
				<h3>Extras</h3>
				<ul>
				<li><a href="indexd773.html?route=product/manufacturer">Brands</a></li>
				<li><a href="index4dd2.html?route=account/voucher">Gift Vouchers</a></li>
				<li><a href="index3d18.html?route=affiliate/account">Affiliates</a></li>
				<li><a href="indexf110.html?route=product/special">Specials</a></li>
				</ul>
			</div>
			<div class="col-sm-3">
				<h3>My Account</h3>
				<ul>
				<li><a href="indexe223.html?route=account/account">My Account</a></li>
				<li><a href="indexe223.html?route=account/order">Order History</a></li>
				<li><a href="indexe223.html?route=account/wishlist">Wish List</a></li>
				<li><a href="indexe223.html?route=account/newsletter">Newsletter</a></li>
				</ul>
			</div>			
			
		</div>
	</div>
	</div>
	<div class="container">
	<div class="row">
		<div class="col-sm-12">
			<div id="powered">
					<span>Powered By <a href="http://www.opencart.com/">OpenCart</a><br /> Drug Store &copy; 2014<!-- [[%FOOTER_LINK]] --></span>				
			<div class="social">		
				<ul>						
					<li><a href="http://facebook.com/" class="tooltip-2" title="Facebook"><i class="fa fa-facebook"></i></a></li>
					<li><a href="https://twitter.com/" class="tooltip-2" title="Twitter"><i class="fa fa-twitter"></i></a></li>
					<li><a href="#" class="tooltip-2" title="RSS"><i class="fa fa-rss"></i></a></li>								
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			<div class="clear"></div>
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</div></footer>
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